Jan. 1 is looming. That's when most Americans will either get insurance through their employers or through health care exchanges as required by the Affordable Care Act. About 5 million people in California are expected to buy insurance through Covered California, the state's exchange.

Scrambling behind the scenes is a giant industry trying to figure out how to offer quality care and make money in a shifting health care marketplace.

Three health care executives spoke frankly about the industry's response to the Affordable Care Act at UC Irvine's University Club.

The success of health care in the United States hinges primarily on two things, industry executives say: healthy people getting into the insurance pool, which would theoretically lower the cost of insurance for everyone; and the ability of the health care industry to manage patient care in a more effective and efficient way. That would be true with or without the Affordable Care Act.

UC Irvine recently hosted a panel discussion of health care executives who weighed in on how the industry is adapting to the changing marketplace and the new law. Here's some of what they said:

DR. RICHARD AFABLE

Chief executive of Covenant Health Network, a group of hospitals

The Affordable Care Act will give people access to health care. But what kind of health care?

"The problem with what we have designed is it doesn't really address the care elements very well, or in enough depth, to make a significant difference."

The Affordable Care Act will need to be tweaked and improved over time, he said. In the meantime, health care providers need to make their own improvements.

"Hospitals are component parts of a discordant, uncoordinated system of care." The hospital business, which is the most visible and most expensive part of health care, works backward, he said. "We wait for people to get sick and we treat them. It's a retrospective view of care."

That needs to change, especially given that providers are set to get smaller payments going forward.

How can hospitals reduce costs sufficiently enough to survive with smaller payments? For hospitals such as Hoag Hospital, that's a big challenge.

Hospitals around the country are coming together to coordinate care to enable efficiencies and sharing of resources that will allow them to thrive with lower payments, he said. Hospitals are looking for partnerships and relationships with health insurers, pharmaceutical companies, long-term care providers and others.

There is fear and concern, but also optimism, in the industry, he said.

"Most of the people that I know working for hospital systems are happy about this change," he said. "They feel like we're finally getting down and around to what we really want to do in the first place, which is to take care of people, as opposed to hope that we can get doctors to refer sick patients to our buildings."

DR. KEITH WILSON

Vice president of clinical services for Molina Healthcare Inc., a managed health care provider for people covered by Medicaid

"Do we have the best health care system in the world?" The answer: It depends on where you sit. "Some people are very happy with their care." But a disproportionate number of people don't have health care, he said.

The system of care and its delivery to patients has long been in need of change, he said. National health care expenditures are 17 percent of the country's gross domestic product. In 20 years, it will be 38 percent.

The Affordable Care Act is not the cause of the nation's broken health care system, he said. It's the reaction. Health care providers have been dealing with market forces for a long time, he said.

Those forces include a Medicare system that's running out of money, the impending health care costs of senior baby boomers, and incomes not keeping pace with the out-of-control costs of health care in the United States compared with other industrialized nations, he said.

"These are the forces that created and drove the need and demand for health care reform," he said.

Health care has been a cottage industry, with individual physicians starting practices, but that will no longer work going forward, he said. "If each doctor is supporting their own infrastructure, their own brick and mortar, their own work staff, that's not a very efficient model."

The formation and consolidation of doctor groups is the trend. "Physicians have to move into larger, more efficient delivery models of health care," he said.

Mid-level practitioners, such as nurses who have advanced degrees, will also be in demand through 2030, when the industry is projected to be short 25,000 physicians.

"Health care is in transition," he said. "There are a ton of patients about to launch on the shores of health care, whether we're ready for them or not."

CHRISTOPHER DE ROSA

Western regional president of Cigna Corp., a managed care provider

Employers must offer insurance that is affordable, which is considered less than 9.5 percent of an employee's annual family income. Since employers don't know what an employee's family income is, they should make sure it's less than 9.5 percent of the worker's income.

The Affordable Care Act will have plenty of bumps along the way. There are sure to be unintended consequences that will need fixing, he said.

Critical to the Affordable Care Act's success is getting healthy people into the insurance pool.

To that end, get ready for an onslaught of advertising, he said.

There will be a concerted effort to get people signed up for insurance. California is slated to spend $280 million between July and October informing people that in about six months most people will need to have health insurance.

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